Should I send my patient with previous giant cell arteritis for imaging of the thoracic aorta? Consensus score: 9.61. Kate Gilbert – Representative of PMRGCAuk. Patients with suspected GCA should be evaluated by a clinician with appropriate specialist expertise, usually a rheumatologist. Imaging may also be useful for follow-up assessments. Lorna Neil – Chair of PMR-GCA Scotland. QoE: ++. Frank Buttgereit – Consultancy fees, honoraria and/or travel expenses from Horizon Pharma, Mundipharma, Roche and Pfizer and grant/study support from Horizon Pharma and Mundipharma. The underlying evidence and additional explanatory notes are presented in more detail in the full guideline document. Disclaimer: The views expressed are those of the authors and not necessarily those of the National Institute for Health Research or the UK Department of Health and Social Care. Conditional recommendation: Glucocorticoid dose should be tapered to zero over 12–18 months, providing there is no return of GCA symptoms, signs or laboratory markers of inflammation. It is also known as cranial arteritis or giant cell arteritis. For details concerning each section please refer to the full guideline published online. Consensus score: 9.81. Table 1 summarizes recommended assessments for patients with GCA. The doctor may recommend supplements such as calcium and vitamin D, and exercises such as walking or weight-bearing exercises, to prevent osteoporosis. Many patients with GCA have inflammation of the aorta and its proximal branches (extracranial large-vessel involvement), which can lead to aortic aneurysm, dissection or rupture [4]. Published by Oxford University Press on behalf of the British Society for Rheumatology. A proposed list of clinical assessments that could be carried out at or near diagnosis of GCA, Features of GCA relevant to prognosis: fever, sweats or weight loss; ischaemic manifestations (jaw claudication, tongue claudication), Signs and symptoms indicating involvement of extracranial arteries, e.g. If you have giant cell arteritis, your doctor will start you on medication right away to prevent vision loss and other problems. Difficult-to-treat rheumatoid arthritis: contributing factors and burden of disease, A rare case of small-vessel necrotizing vasculitis of the bone marrow revealing granulomatosis with polyangiitis, Defining colchicine resistance/intolerance in patients with familial Mediterranean fever: a modified-Delphi consensus approach, Real-world single centre use of JAK inhibitors across the rheumatoid arthritis pathway, The management of Sjögren’s syndrome: British Society for Rheumatology guideline scope, About the British Society for Rheumatology, https://doi.org/10.1093/rheumatology/kez664, treatment This is the executive summary of British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis, doi: 10.1093/rheumatology/kez672, https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model, Receive exclusive offers and updates from Oxford Academic, British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis, Large vessel giant cell arteritis suggested by magnetic resonance imaging of the thigh: a potential mimicker of myositis, fasciitis and skeletal muscle vasculitis, Large-vessel involvement in recent-onset giant cell arteritis: a case–control colour-Doppler sonography study, Prognosis of large-vessel giant cell arteritis, Giant cell arteritis and polymyalgia rheumatica: usefulness of vascular magnetic resonance imaging studies in the diagnosis of aortitis. ‘General principles’ are not necessarily evidence-based but are a description of generally accepted best medical practice. GCA is therefore a medical emergency requiring immediate treatment. TSH: thyroid stimulating hormone; DXA: dual-energy X-ray absorptiometry. If GCA is strongly suspected, the first dose of glucocorticoid can be given without waiting for laboratory results. Giant cell arteritis (GCA) is a medical emergency. 4. National and society guidelines for the secondary prevention of coronary and other atherosclerotic vascular diseases should be followed. Patients receiving high-dose glucocorticoids are at an elevated risk of osteoporosis and bone fracture; this risk should be managed appropriately. It primarily affects branches of the external carotid artery, and it is the most common form of systemic vasculitis in adults. Consensus score: 9.17. The routine use of cholesterol-lowering agents such as statins for GCA is not recommended. 1,2 Initially GCA was considered a vasculitis affecting the carotid and vertebral artery branches only but was later redefined to include all medium and large vessels when autopsies showed involvement of large vessels in 80% of cases. Most occurrences of blindness or stroke happen either before treatment or during the first week of treatment [3]. Conditional recommendation: 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), magnetic resonance angiography (MRA), computed tomography angiography (CTA) or axillary artery ultrasound may be used to evaluate involvement of the aorta and its proximal branches. Marwan Bukhari – Involvement in the GCA Consortium, which is indirectly funded by Roche/Chugai. Ultrasound can assess the axillary arteries, but ultrasound evaluation of the deeper arteries is more difficult. More information on accreditation can be viewed at www.nice.org.uk/accreditation. Raashid Luqmani – Grants, honoraria and travel support for EULAR 2019 from Roche/Chugai. All rights reserved. It brings the latest peer-reviewed evidence up-to-date and supports clinicians in providing the best treatment for people with GCA. Dr Mackie continues: “This guideline provides a coherent statement of what is the latest best practice. Too often our charity learns of cases of people losing all or some of their sight needlessly because diagnosis was delayed, or the wrong treatment given. Patients should be signposted to relevant patient support groups or charities as sources of peer support. Early diagnosis of diabetic peripheral neuropathy based on infrared thermal imaging technology. For permissions, please email: journals.permissions@oup.com, This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (. We've published an updated guideline on the treatment of giant cell arteritis (GCA), a condition diagnosed in around 2,500 people in the UK every year. On suspicion of GCA, primary care providers should initiate glucocorticoids alongside an urgent referral to the local GCA pathway. Conditional recommendation: Methotrexate might be considered for GCA, in combination with a glucocorticoid taper, in patients at high risk of glucocorticoid toxicity or who relapse. Depending on the clinical situation, initiation of glucocorticoid treatment in primary care may be advised — the standard initial dose for GCA without visual symptoms is 40–60 mg oral prednisolone per day. Please email Membership on subscriptions@rheumatology.org.uk with any queries. Clinicians should be aware of an increased risk of thoracic aortic aneurysm and dilatation; this may occur at any time during the disease course [4]. QoE: insufficient evidence. Objectives: To provide guidance for clinicians in the diagnosis and treatment of GCA, supported by evidence where possible. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. All taper schedules assume close and regular clinical follow-up and good communication between patients and care providers should symptoms change (see Tables 2 and 3). It's serious and needs urgent treatment. 8. Blood tests cannot confirm if you have giant cell arteritis (GCA), they can show whether your body has inflammation (swelling). Early treatment with effective doses of glucocorticoids may prevent serious complications such as vision loss. Severe, incapacitating stiffness in her arms and shoulders was worse in the morning and decreased by the middle of the afternoon. TNF inhibitors are not recommended in GCA. Visual loss occurs in up to a fifth of patients, which may be preventable by prompt recognition and treatment. Treatment. Patients in whom GCA is strongly suspected should be immediately treated with high-dose glucocorticoids. If you have giant cell arteritis, your doctor should also look for signs of another disorder, polymyalgia rheumatica. Correspondence to: Sarah L. Mackie, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Harrogate Road, Leeds, UK. For doses, see Treatment of GCA, below. GCA typically occurs in people 50 years of age or older and is more common in women. It is therefore necessary to provide clear guidance about current best practice and the underlying evidence including areas of uncertainty. The standardised approach to care outlined in the guidelines supports clinicians in conversations with their managers about developing business cases for investment in this area. High dose glucocorticoid therapy (40–60 mg/day prednisone-equivalent) should be initiated immediately for induction of remission in active giant cell arteritis (GCA) or Takayasu arteritis (TAK). GCA is a medical emergency and therefore ‘fast-track’ referral pathways for urgent specialist evaluation of suspected GCA are beneficial. Giant cell arteritis is treated with medications, such as prednisone. 1. Refer patients with suspected GCA and visual symptoms such as blurring, diplopia, or visual loss immediately to ophthalmology specialists, as untreated GCA with eye involvement can lead to loss of eyesight. Consensus score: 9.61. Each general principle carries a consensus score (mean rating on a 0–10 scale). bruits, different blood pressures in the two arms, limb claudication, Ophthalmological evaluation for patients with transient or permanent visual loss or diplopia, History of comorbidities and medications that might predispose to glucocorticoid-related adverse effects: infection, hypertension, diabetes, osteoporosis, low-trauma fracture, dyslipidaemia, peptic ulcer, psychiatric adverse effects, Features that may suggest alternative diagnosis, e.g. Dr Sarah Mackie, Associate Clinical Professor in Vascular Rheumatology at the University of Leeds, co-led the development of the guideline, working with over 35 national and international experts in the field, including rheumatologists, GPs, ophthalmologists and patients. She said that her older brother had bee… Methotrexate, which may be given orally or by subcutaneous injection, has been used at doses of 7.5–15 mg weekly in clinical studies and up to 25 mg weekly in clinical practice. Virtual Advisory Board Member for Roche/Chugai on GCA. During glucocorticoid tapering and after glucocorticoid cessation, patients should be informed what symptoms may suggest GCA relapse and what action the patient should take in these circumstances, including first point of contact for medical advice and how to contact the team providing specialist care. Does this patient have temporal arteritis? On the basis of three randomized controlled trials, conducted in patients with recent-onset GCA, the evidence for methotrexate as a glucocorticoid-sparing agent in GCA remains equivocal, acknowledging limitations of the evidence base. For relapse management, see Table 3. However, she reported a general sense of malaise, fatigue and weakness, and she appeared to be moderately depressed. For this reason, giant cell arteritis is sometimes called temporal arteritis.Giant cell arteritis frequently causes headaches, scalp tenderness, jaw pain and vision problems. Consensus score: 9.28. Humphrey Hodgson, Chair of Trustees for PMRGCA UK, says it's vital the guideline is rolled out across the UK: “These new guidelines have the power, if implemented fully, to transform the diagnosis and treatment of giant cell arteritis. The guideline also includes practical information for clinicians including what symptoms to check, what tests to do, steroid dosing and care pathways. Commonly, patients may have carotidynia, audiovestibular symptoms, double vision, and aortic aneurysm Biomedical Research,. ; this risk should be managed appropriately to ensure clinicians have the latest practice! 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